Clinical Judgment and Nursing Process Flashcards

Vocabulary flashcards covering the nursing process, clinical decision-making layers, data types, clinical reasoning phases, prioritization frameworks, and Maslow's hierarchy of needs.

Nursing Process

A systematically organized framework used to identify a client's health status and actual or potential healthcare problems, establish plans to meet identified needs, and deliver specific nursing interventions to achieve optimal outcomes.

Assessment

The first step of the nursing process, defined as the process of systematically collecting, verifying, organizing, interpreting, and documenting patient data to be utilized by healthcare professionals.

Subjective Data

Information gathered directly from what the patient tells the nurse, representing the patient's point of view, feelings, perceptions, concerns, or symptoms (e.g., pain, dizziness, nausea, shortness of breath).

Objective Data

Observable and measurable data obtained through physical examination, observation, laboratory tests, and diagnostic testing, also known as signs (e.g., vital signs, bleeding, lab results).

Primary Source

A source of assessment data obtained directly from the person being examined.

Secondary Source

A source of assessment data obtained from indirect origins such as family members, healthcare providers (HCP), or medical records.

Diagnosis (Nursing Process)

The phase of the nursing process that involves analyzing data, synthesizing and interpreting findings, and identifying actual or potential health problems, risks, and client strengths.

Planning (Nursing Process)

The phase of the nursing process where goals and outcomes are formulated to provide direction for nursing interventions, categorized into initial planning, ongoing planning, and discharge planning.

Implementation (Nursing Process)

The phase of the nursing process where the nurse puts the treatment plan into effect by executing designated nursing interventions.

Evaluation (Nursing Process)

The final phase of the nursing process involving collecting data, comparing collected data with desired outcomes, analyzing client response, identifying factors of success or failure, and continuing, modifying, or terminating the plan of care.

Layered Clinical Judgment Model (NCJMM)

A framework organizing clinical decision-making across layers, connecting client needs to clinical judgments, hypothesis processing (Form hypotheses, Refine hypotheses, Evaluation), six core cognitive steps, and contextual environmental and individual factors.

Clinical Decision Making Wheel

An integrated conceptual framework illustrating the direct alignment between the five phases of the Nursing Process and the six cognitive actions of Clinical Decision Making.

Recognize Cues

The clinical reasoning phase corresponding to Assessment that involves detecting or noticing client signs, symptoms, and safety risks.

Analyze Cues

The clinical reasoning phase corresponding to Diagnosis that involves organizing, synthesizing, and interpreting collected data to understand patient health situations.

Prioritize Hypotheses

The clinical judgment step under Diagnosis involving differential diagnosis and weighing the probability of related problems to establish priority concerns.

Generate Solutions

The clinical judgment step corresponding to Planning that involves predicting complications, anticipating consequences, considering actions, setting priorities, and formulating desired outcomes.

Take Actions

The clinical judgment step corresponding to Implementation that involves performing evidence-based interventions, monitoring responses, reflecting, and making adjustments.

Evaluate Outcomes

The clinical judgment step corresponding to Evaluation that involves reflecting on patient progress and repeating ADPIE phases as indicated.

Clinical Reasoning Phases

A structured clinical care process detailing the cognitive actions of Assessing, Diagnosing, Planning, Implementing, and Evaluating alongside their expected clinical judgment outcomes.

Maslow's Hierarchy of Needs

A prioritization model structuring human needs into five levels: Biological & Physiological, Safety, Love/belonging, Esteem, and Self-actualisation.

Biological & Physiological Needs

The base level of basic needs in Maslow's Hierarchy, encompassing fundamental survival necessities such as food, sleep, and water.

Safety Needs

The second level of basic needs in Maslow's Hierarchy, focusing on security, health, and financial stability.

Love/Belonging Needs

The third level of Maslow's Hierarchy, representing psychological needs related to friendship, intimacy, family, and social connections.

Esteem Needs

The fourth level of Maslow's Hierarchy, representing psychological needs concerning respect, status, recognition, strength, and self-esteem.

Self-Actualisation

The highest level of self-fulfillment needs in Maslow's Hierarchy, defined as meeting one's full potential in life.

ABC Priority Framework

A fundamental prioritization mnemonic standing for Airway, Breathing, and Circulation used to identify and address life-threatening physiological needs first.

Environmental Factors (NCJMM Layer 4)

External elements influencing clinical decisions, including environment, client observation, resources, medical records, consequences & risks, time pressure, task complexity, and cultural consideration.

Individual Factors (NCJMM Layer 4)

Clinician-specific characteristics influencing clinical judgment, including knowledge, skills, specialty, candidate characteristics, prior experience, and level of experience.